HomeMy Public PortalAbout6137 SULTANA AVE_Sewer__ 24650 INSERTS y
76x641)sa APPLICATION FOR PERM T
COUNTY OF LOS ANGELES SEWER--SEWAGE DISPOSAL
DEPARTMENT OF COUNTY ENGINEER
BUILDING AND SAFETY DIVISIONBUILDING �r 777
ADDRESS J'`
JOHN A. LAMBIE, County Enggineer
WILLIAM& JENSEN, Supt of Beulding LOCALITY
NEAREST �f
FOR APPLICANT TO IN CROSS ST. 4C+
LEGAL
OWNER
DESCRIPTION T 10,
BLOCK TRACT �_( MAIL
.d"r7 ADDRESS
N0.OF BLDGS.
SIZE OF LOT NOW ON LOT CITY TEL, NO,
USE OFDI DISTRICT NO..; GROUP MAP PROCESS`x BY
BU%LDINGS �''�"'"' ' Fes" BK PG ,rte" �{
CONTRACTOR o X .`�-° '� ^"' ,! °`"'
"-1�^"'"`'' 44,rx
ADDRESS ' , f CONMCTION DATA
CITY TEL.N0,/_, n eya,t,A 4,C- STATION / I DEPTH
❑ STATE MANHOLE REFERENC '
REGISTRATION NO. ��3 +� [] COUNTY F '
No �DESCRIPT Of N OF WORK FEE
HOUSE SFV FR CONNECTING TO
PUBLIC SEWER $3.00 : �r�:� '"'—
TYPE T_IONi LENGTH FROM =Y`
SEPTIC TANK SEEPAGE PIT OR Y. - P.L. 3 M. 7'0 P.L.
PIT'S AND/OR DRAINFIELD @ $3..00 -
OVERFLOW SEEPAGE?IT. DRAINFIELD
EXT'N..CESSPOOL DRYWELL @ $2.00 � 3 �•- P.C.NO
HOUSE SEWER"ONN€CTING TO CO.IMP. N0. S' ' :JOB
PRIVATE DISPOSAL SYSTEM @ $1.00 ya
CONNECT ADDITIONAL BLDG,OR TRUNK PERMIT N0. k= ..-'�e+.." bD N �-�� O
WORK TO HOUSE SEINER, - @ $1.00 U
ANTER.: REPAIR OR ABANDON HOUSE STATE ENCROACHMENT g�
SEWER OF DISPOSAL SYSTEM @ $1.00 PERMIT NO.
INDUSTRIAL. R?
WASTE APPROVAL
CHARGES
OV+ EER'S PERMIT $ 21 00 CONNECTION CHARGE FEE
AUTHORIZATION TOTAL FEE I ti .� REIMBURSEMENT FEE
I HAVE AT THIS DATE A CONTRACT WITH THE HEREIN NAMED CON-
TRACTOR TO CONNECT THE ABOVE DESCRIBED EXISTING"DWELLING APPROVALS I DATE INSPECTOR'S SIGNATURE
TO THE PUBLIC SEWER.
SIGNED THIS DAY OF X19- NEW HOUSE SEWER
OWNER ORCONNECT ADDITIONAL
AGENT.GENT.v '� >� '.-„.�,.o� BUlLD1NG OR WORK
c
ADDRESS SEPTIC TANK,SEEP.PIT(S)
--”- -- _ AND/OR DRAINFIELD
I HEREBY ACKNOWLEDGE THAT I HAVE READ THIS APPLICATION
AND STATE THAT THE ABOVE 15 CORRECT AND AGREE TO COMPLY CESSPOOL El DRYWELL
WITH ALL COUNTY ORDINANCES AND STATE LAWS REGULATING ALTER,REPAIR,SEWER Or,
AND SEWERS. SEWAGE DISPOSAL SYSTEM
I HEREBY CERTIFY THAT I AM PROPERLY REGISTERED AND/OR DISCONNECT PLUG AND
LICENSED AS REQUIRED BY LOS ANGELES COUNTY AND STATE OF ABANDON HOUSE SEWER
CALIFORNIA OR THAT I AM THE LEGAL OWNER OF THE 'ABOVE
DESCRIBED RESIDENTI L *OPERTY. BACKFILL SEPTIC TANKS [I
SIGNATURE /� SEEP,PI'T($) I CESSPOOLS [1
OF PERMITTEE- 4 ,1
-
VALIDATION" ROBERT A. WOOD
CM. ml 0, CASH SUPERVISING fdEC:HANICAL ENGINEER
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